Hold Off on Antibiotics for Sinus Infection, Guidelines Urge

Action Points

New guidelines for acute sinusitis address issues that include the inability of existing clinical criteria to accurately differentiate bacterial from viral acute rhinosinusitis and excessive and inappropriate antimicrobial therapy.

Point out that the guidelines recommend empiric antimicrobial therapy with amoxicillin-clavulanate rather than amoxicillin alone when the clinical diagnosis of acute bacterial rhinosinusitis is established.

Between 90% and 98% of sinus infections won't respond to antibiotics, so doctors should hesitate before reaching for the prescription pad, according to new guidelines for the treatment of rhinosinusitis from the Infectious Diseases Society of America.

"There is no simple test that will easily and quickly determine whether a sinus infection is viral or bacterial, so many physicians prescribe antibiotics 'just in case,'" commented Anthony Chow, MD, of the University of British Columbia in Vancouver, who chaired the panel that developed the guidelines.

But, he added in a statement, "if the infection turns out to be viral -- as most are -- the antibiotics won't help and in fact can cause harm by increasing antibiotic resistance, exposing patients to drug side effects unnecessarily and adding cost."

The guidelines, published online in Clinical Infectious Diseases, offer primary care physicians 18 recommendations to help ensure appropriate treatment, ranging from how to tell bacterial from viral infections to when to call in a specialist.

Although most cases are viral, the guidelines suggest suspecting a bacterial cause when:

Symptoms or signs are persistent, lasting at least 10 days without any evidence of clinical improvement.

The disease onset is characterized by severe symptoms or signs of high fever (of at least 39° C or 102° F) and purulent nasal discharge or facial pain lasting for at least three or four days.

The disease gets worse with a new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection that lasted five or six days and had appeared to be improving.

Where a bacterial cause is likely, the guidelines suggest prompt treatment with an antibiotic.

Many previous guidelines had suggested empiric therapy with the beta-lactam antibiotic amoxicillin, but an increasing proportion of respiratory pathogens now produce beta-lactamase, which breaks down the drug.

So, the new guidelines say, initial therapy should add clavulanate, a beta-lactamase inhibitor, to the amoxicillin.

The recommendation applies to both adults and children.

Because of increasing rates of drug resistance, the guidelines also recommend not using other common antibiotics, including azithromycin (Zithromax), clarithromycin (Biaxin), and trimethoprim-sulfamethoxazole (Septra).

The new guidelines also say that a shorter treatment time for adults -- five to seven days, rather than 10 to 14 -- is long enough to treat a bacterial infection without encouraging resistance.

Children should still be treated for 10 days to two weeks, the guidelines say.

Regardless of the cause of the infection, the guidelines discourage decongestants and antihistamines, which don't help and in some cases can make symptoms worse.

On the other hand, nasal steroids can help ease symptoms in people who have sinus infections and a history of allergies.

Saline nasal irrigation might help relieve some symptoms, the guidelines say, although it might not be as helpful in children because of the discomfort of the therapy.